Primary care doctors would need more than 24 hours per day to provide recommended care

Following national recommendation guidelines for preventive, chronic disease and acute care would take a primary care physician 26.7 hours per day to see an average number of patients, a new study finds.

That breaks down to 14.1 hours/day for preventive care, 7.2 hours/day for chronic disease care, 2.2 hours/day for acute care, and 3.2 hours/day for documentation and inbox management.

The research, conducted by the University of Chicago, Johns Hopkins University, and Imperial College London, used a simulation study to compute time per patient based on data from the National Health and Nutrition Examination Survey.

"There is this sort of disconnect between the care we've been trained to give and the constraints of a clinic workday," said Justin Porter, MD, Assistant Professor of Medicine at the University of Chicago and lead author of the paper. "We have an ever-increasing set of guidelines, but clinic slots have not increased proportionately."

The study also looked at physician time as part of a team, where nurses, physician assistants, counselors and others help to deliver recommended care.

It found that team-based care reduced the time a physician needed to deliver care to 9.3 hours/day, broken into 2.0 hours/day for preventive care, 3.6 hours/day for chronic disease care, 1.1 hours/day for acute care, and 2.6 hours/day for documentation and inbox management.

"Team-based care is a movement that has been around in medicine for a while and has gathered steam more recently," said Porter. "Doctors do not give care in a vacuum. There are other extremely important members of the healthcare team that are working together and often independently to provide care for patients. This is a huge opportunity and partial solution to the time constraints currently faced in medical care."

The study is published in the Journal of General Internal Medicine.

Adding to the evidence

This new study joins and builds on others that have found a discrepancy between guidelines and a physician's time.

In 2003, a Duke University study estimated it would take a primary care physician 7.4 hours/day to provide preventive care for an average-sized patient population, while a 2005 study from Mount Sinai found it would take 8.6 hours/day. A complementary study from Duke in 2005 calculated an additional 10.6 hours/day to manage the Top 10 chronic diseases. Together, that indicates a doctor would need at least 18 hours/day to provide both preventive and chronic care.

The new study went one step further by including all types of care a primary care physician provides—preventive, acute, and chronic—as well as administrative tasks, and accounted for changes to the guidelines that have occurred since the earlier studies were published. It also used a different methodology, employing real patient data from an annual national survey to calculate its results. The earlier studies used hypothetical patient populations based on the U.S. population.

"When you're dealing with real people, you have more complexity to the data. A person may have multi-morbidity, or several chronic diseases at once," said Porter. "That patient would be treated differently than a hypothetical, average patient. This leads to more comprehensive and precise calculations."
The study's data on team-based care also expanded the information available on time constraints for primary care physicians.

The researchers used the Comprehensive Primary Care Plus (CPC+) model to develop the estimates for team-based care. The model allows physicians to focus on advanced care and brings in specialized medical professionals to take over other areas. Dietitians, for instance, would handle nutritional counseling for patients with diabetes or obesity, a time-intensive task. Overall, the researchers determined that 65% of primary care services could be handled by other team members.

More time, better care

Moving to a team-care model would require systemic changes to the way Americans pay for care. Currently, payment for many counseling services depends on patients having a qualifying disease. Yet the benefits of team-based care make the effort worth it, the researchers say.

The time pressure that physicians face has real consequences for the delivery of healthcare. According to the researchers, time constraints are a key factor in physician burnout, one of the drivers pushing medical students from the field.

For patients, the researchers say, time pressure helps explain why improvements in outcomes have not kept pace with advances made in the field. It plays a role in inequities in health care, with vulnerable populations typically receiving care at overburdened clinics. It also has an impact on patient satisfaction.

"If you do surveys with patients about what frustrates them about their medical care, you'll frequently hear, 'My doctor doesn't spend time with me' or 'My doctor doesn't follow up,'" said Porter. "I think a lot of times this is interpreted as a lack of empathy, or a lack of willingness to care for a patient. But the reality—for the majority of doctors—is simply a lack of time."

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